Provider Demographics
NPI:1932510500
Name:PEDERSEN, ERIC (LPC, LCPC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CMR 411
Mailing Address - Street 2:BOX 6025
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112
Mailing Address - Country:US
Mailing Address - Phone:1517-261-6192
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC BAVARIA
Practice Address - Street 2:CMR 411, BLDG 700, ROSE BARRACKS
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112
Practice Address - Country:US
Practice Address - Phone:49966-283-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178004187101Y00000X
IL180008617101YP2500X
FLIMT 1741106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOMedicare UPIN